Florida Department of Elder Affairs 701A Condensed Assessment Rule: 58-A-1.010, F.A.C.

Transcription

1 Florida Department of Elder Affairs 701A Condensed Assessment Rule: 58-A-1.010, F.A.C. Provider ID: Assessor/Case Manager (CM) Name: Provider Assessor/CM ID: Signature: A. DEMOGRAPHIC SECTION 1. ASSESSOR/CM: What is the purpose of this assessment? Initial Annual Health Living situation Caregiver Environment Income 2. Social Security number: 3. Name: a. First: b. Middle initial: c. Last: 4. Medicaid number: 5. Phone number: 6. Date of birth (mm/dd/yyyy): 7. Sex: Male Female 8. Race (Mark all that apply): White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Other 9. Ethnicity: Hispanic/Latino Other 10. Primary language: English Spanish Other: 11. Does client have limited ability reading, writing, speaking, or understanding English No Yes 12. Marital status: Married Partnered Single Separated Divorced Widowed 13. ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.) a. Street: b. City: c. ZIP code: d. Type: Private residence Assisted living facility (ALF) Nursing facility Hospital Adult day care Other e. Name: 14. Home Address (If different from current physical location) a. Street: b. City: c. ZIP code: 15. Is client s home address public housing? No Yes 16. Mailing Address (If different from current physical location) a. Street: b. City: c. State: d. ZIP code: 1 DOEA 701A, April 2013

2 17. ASSESSOR/CM: Assessment date: (mm/dd/yyyy) 18. ASSESSOR/CM: Assessment site: Home ALF Nursing facility Hospital Adult day care Other 19. ASSESSOR/CM: Referral date: (mm/dd/yyyy) 20. ASSESSOR/CM: Referral source: Self/Family Nursing facility Case management agency CARES Aging out Hospital Department of Children and Families Other APS; Select level of APS risk: High Intermediate Low 21. ASSESSOR/CM: Transitioning out of a nursing facility? No Yes 22. ASSESSOR/CM: Imminent risk of nursing home placement? No Yes 23. Are you enrolled on a special needs registry? No Yes 24. Is there a primary caregiver? No Yes 25. Living situation: With primary caregiver With other caregiver With other Alone 26. Individual monthly income: $ Refused 27. Couple monthly income: $ Refused N/A 28. Estimated total individual assets: $ $0 to $2,000 $2,001 to $5,000 $5,001 or more Refused 29. Estimated total couple assets: $ $0 to $3,000 $3,001 to $6,000 $6,001 or more Refused N/A 30. Are you receiving S/NAP (food stamps)? No Yes 31. Do you need other for food? No Yes 32. ASSESSOR/CM: Is someone besides the client providing answers to questions? No (Skip to 33) Yes a. Name: b. Relationship: 33. Besides your own children, how many children under age 19 do you live with and provide care for? (if 0, skip to 34) # a. How many are grandchildren? # Name(s): b. How many are other related children? # Name(s): c. How many are other non-related children? # Name(s): 34. How many disabled adults age 19 to 59 do you live with and provide care for? (if 0, skip to 35) a. How many are grandchildren? # Name(s): # b. How many are other relatives? # Name(s): c. How many are other non-relatives? # Name(s): Notes & Summary 2 DOEA 701A, April 2013

3 B. MEMORY SECTION Florida Department of Elder Affairs: 701A Condensed Assessment 35. Has a doctor or other health care professional told you that you suffer from memory loss, cognitive impairment, any type of dementia, or Alzheimer s disease? No Yes 36. Have you become concerned about your memory or had problems remembering important things? No Yes C. GENERAL HEALTH, SENSORY & COMMUNICATION IMPAIRMENT SECTION 37. How would you rate your overall health at this time? Excellent Very Good Good Fair Poor 38. Compared to a year ago, how would you rate your health? Much better Better About the same Worse Much worse 39. How many times have you fallen in the last six months? # 40. How often are there things you want to do but cannot because of physical problems? Never Occasionally Often All of the time 41. When you need medical care, how often do you get it? Always Most of the time Rarely Only in an emergency Never 42. When you need transportation to medical care, how often do you get it? Always Most of the time Rarely Only in an emergency Never 43. How often do finances/insurance allow you to obtain health care and medications when you need them? Always Most of the time Rarely Only in an emergency Never 44. Have you visited the emergency room (ER) or been admitted to the hospital within the last year? No Yes: How many times? ER# Hospital # 45. In the last year were you in a nursing or rehabilitation facility? No Yes 3 DOEA 701A, April 2013

4 D. ACTIVITIES OF DAILY LIVING SECTION 46. How much do you need with the following tasks? Task No needed Uses assistive device Needs supervision or prompt Needs (but not total help) Needs total (cannot do at all) a. Bathing b. Dressing c. Eating d. Using the bathroom e. Transferring f. Walking/Mobility 47. How much do you have with the following tasks? Task No needed Always has Has most of the time Rarely has Never has a. Bathing b. Dressing c. Eating d. Using the bathroom e. Transferring f. Walking/Mobility 4 DOEA 701A, April 2013

5 E. INSTRUMENTAL ACTIVITIES OF DAILY LIVING SECTION 48. How much do you need with the following tasks? Task No needed Uses assistive device Needs supervision or prompt Needs (but not total help) Needs total (cannot do at all) a. Heavy chores b. Light housekeeping c. Using the telephone d. Managing money e. Preparing meals f. Shopping g. Managing medication h. Using transportation 49. How much do you have with the following tasks? Task No needed Always has Has most of the time Rarely has Never has a. Heavy chores b. Light housekeeping c. Using the telephone d. Managing money e. Preparing meals f. Shopping g. Managing medication h. Using transportation 5 DOEA 701A, April 2013

6 F. HEALTH CONDITIONS & THERAPIES SECTION 50. Have you been told by a physician that you have any of the following health conditions? ASSESSOR/CM: Indicate whether a problem occurred in the past by marking the first box and when a problem is current by marking the second box. Mark all that apply. Past Current Health Conditions Acid reflux/gerd Allergies, list: Amputation, site: Anemia Severe Moderate Mild Arthritis, type: Bed sore(s) (Decubitus), location: Blood pressure High Low Broken bones/fractures, location: Cancer, site: Chlamydia Cholesterol High Low Dehydration Diabetes IDDM NIDDM Dizziness Constant Frequent Occasional Rare Fibromyalgia Gallbladder Removal Problems Gonorrhea Heart problems Pacemaker CHF MI Other Head, brain, or spinal cord trauma Herpes Human Immunodeficiency Virus (HIV) Human Papillomavirus (HPV)/Genital warts Incontinence, Bladder Constant Frequent Occasional Rare Incontinence, Bowel Constant Frequent Occasional Rare Kidney problems or Renal disease End stage? No Yes Liver problems Cirrhosis Hepatitis Lung problems Emphysema Asthma Pneumonia COPD Lupus Multiple Sclerosis Muscular Dystrophy Osteoporosis Parkinson s disease Paralysis Full Partial Local, site: Seizure disorder, type & frequency: 6 DOEA 701A, April 2013

7 F. HEALTH CONDITIONS & THERAPIES SECTION, CONTINUED Past Current Health Conditions Shingles Stroke/CVA Syphilis Thyroid problems/graves/myxedema Hyper Hypo Tumor(s), site: Ulcer(s), site: Urinary Tract Infection (UTI) Other: 51. Provide information on the frequency of current therapies or specialty care: Treatment type: N/A or None Monthly Weekly Several times a week Daily Several times a day a. Bladder/bowel treatment b. Catheter, type: c. Dialysis d. Insulin e. IV Fluids/IV Medications f. Occupational therapy g. Ostomy, site: h. Oxygen i. Physical therapy j. Radiation/Chemotherapy k. Respiratory therapy l. Skilled nursing m. Speech therapy n. Suctioning o. Tube feeding p. Wound care/lesion irrigation q. Other therapy, type: 7 DOEA 701A, April 2013

8 G. MENTAL HEALTH SECTION Florida Department of Elder Affairs: 701A Condensed Assessment 52. How satisfied are you with your overall quality of life? Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied 53. Thinking about how you were this time last year, how do you feel about the way things are now? Much better Better About the same Worse Much worse 54. Have you been diagnosed with a mental condition or psychiatric disorder by a health professional? No Yes: List conditions: 55. ASSESSOR/CM: Indicate whether you noticed problem behaviors or any recurring problems have been reported to you by the client, caregiver, in-home worker, family, or staff, and note the frequency of occurrence in the last month. Provide details in the Notes & Summary section, below. Problem behaviors Not at all Once Several days More than half the days a. Forgetful or easily confused b. Gets lost or wanders off c. Easily agitated or disruptive d. Sexually inappropriate e. Threatens or is verbally hostile* f. Physically aggressive or violent* g. Intentionally injures or harms him/herself* h. Expresses suicidal feelings or plans* i. Hallucinates, hears/sees things that are not there* j. Other: Nearly every day *Thoughts of suicide or self-injury, hallucinations, or aggressive behaviors are potentially serious problems that should be reported immediately to a supervisor, primary care physician, emergency care, law enforcement, and/or Adult Protective Services, as appropriate. 56. ASSESSOR/CM: Does client need supervision? No Yes 8 DOEA 701A, April 2013

9 H. NUTRITION SECTION Florida Department of Elder Affairs: 701A Condensed Assessment 57. Do you usually eat at least two meals a day? No Yes 58. Do you eat alone most of the time? No Yes 59. How many cups of water, juice, or other liquid do you drink daily? (If more than eight, skip to 60) # a. Do you ever limit the amount of fluids you drink? No Yes 60. On average, how many servings of fruits and vegetables do you eat every day? (One serving is one small piece of fruit or vegetable, about one-half cup of chopped fruit or vegetable, or one-half cup of fruit or vegetable juice.) # 61. On average, how many servings of dairy products do you have every day? (One serving of dairy is about a slice of cheese, a cup of yogurt, or a cup of milk or dairy substitute.) # 62. Estimate your current height and weight: Height: ft. inches Weight: lbs. 63. Have you lost or gained weight in the last few months? Unsure (Skip to 64) No (Skip to 64) Yes a. How much? Less than five pounds Five to ten pounds Ten pounds or more b. Was the weight loss/gain on purpose (i.e., dieting or trying to lose/gain weight)? No Yes 64. Are you on a special diet(s) for medical reasons? No (Skip to 65) Yes; check any/all: Calorie supplement Low fat/cholesterol Low salt/sodium Low sugar/carb Other a. How long have you been on this diet? b. Why are you on this diet? 65. Do you have any problems that make it hard for you to chew or swallow? No Yes; check any/all: Mouth/tooth/dentures Pain or difficulty swallowing Taste Nausea Saliva production Other, describe: 66. What working appliances do you have for storing/preparing food? None Refrigerator Microwave Toaster/Oven Stove Other: 67. Do you take three or more prescribed or over-the-counter medications a day? No Yes 68. How many days in a typical week do you drink alcohol? Refused (Skip to 69) None (Skip to 69) One to two Three to five Six to seven a. On the days when you have some alcohol, about how many drinks do you usually have? One to two Three to five Six or more b. About how many times in the last month have you had four or more drinks in a day? None One to two Three to five Six or more 9 DOEA 701A, April 2013

10 I. SOCIAL RESOURCES SECTON Florida Department of Elder Affairs: 701A Condensed Assessment 69. If needed, is there someone (besides primary caregiver) who could help you? No (Skip to 71) Yes 70. Do I have your permission to contact this person, if you need help? No (Skip to 71) Yes a. Name: b. Relationship to client: c. Phone: J. CAREGIVER SECTION ASSESSOR/CM: If client has no primary caregiver, stop the assessment here. Otherwise, complete ASSESSOR/CM: HCE Caregiver? If yes, check 72. Caregiver full name: a. First: b. Middle Initial: c. Last: 73. Caregiver date of birth: (mm/dd/yyyy) 74. ASSESSOR/CM: Caregiver identification number 75. Caregiver sex: Male Female 76. Caregiver race (Mark all that apply.): White Black/African American Asian American Indian/ Alaska Native Native Hawaiian/ Pacific Islander Other 77. Caregiver ethnicity: Hispanic/Latino Other 78. Caregiver primary language: English Spanish Other: 79. Caregiver relationship to client: Wife Husband Partner Parent Son/In-law Daughter/In-law Other Relative Other Non-relative 80. Caregiver address: a. Street: b. City: c. State: d. ZIP code: 81. Caregiver phone number: 82. How much of a mental or emotional strain is it on you to provide care for the client? None Some strain A lot of strain 10 DOEA 701A, April 2013

11 J. CAREGIVER SECTION (CONTINUED) 83. Considering other aspects of your life, rate the level of difficulty in your: No difficulty Little difficulty Some difficulty Moderate difficulty A lot of difficulty a. Relationship with client b. Relationship with family c. Relationships with friends d. Physical health e. Finances f. Functional abilities g. Employment h. Time for yourself to do the things you enjoy 84. How confident are you that you will have the ability to continue to provide care? Very confident (Skip to 85) Somewhat confident (Skip to 85) Not very confident a. What is the main reason you may be unable to continue to provide care? 85. ASSESSOR/CM: Is the caregiver in crisis? No Yes; check all that apply: Financial Emotional Physical 86. Ask the caregiver to answer the following about the client. (An answer of Yes, a change indicates that there has been a change in the last year caused by thinking and memory problems.) Yes, a change No change Don t know or N/A a. Problems with judgment (problems making decisions, bad financial decisions, problems with thinking) b. Repeats the same things over and over (questions, stories, or statements) c. Daily problems with thinking or memory Adapted from the Eight-item Informant Interview to Differentiate Aging and Dementia, a copyrighted instrument of Washington University, St. Louis, Missouri. Copyright All rights reserved. 11 DOEA 701A, April 2013

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13 WHY ARE WE COLLECTING YOUR SOCIAL SECURITY NUMBER? We are required to explain that your Social Security number is being collected pursuant to Title 42 Code of Federal Regulations, Section , to be used for screening and referral to programs or services that may be appropriate for you. The provision of your Social Security number is voluntary, and your information will remain confidential and protected under penalty of law. We will not use or give out your Social Security number for any other reason unless you have signed a separate consent form that releases us to do so. 13 DOEA 701A, April 2013